ABSTRACT: PROJECT 1 – Novel Biomarker Strategies Peripheral blood-based HCC biomarker panels are an essential component of early detection strategies, especially in remote AI/AN tribal communities and Indian reservations that are very far from any imaging facilities. Additionally, blood-based biomarker screening achieves greater compliance than imaging-based screening, even when imaging is readily available. Promising serum biomarker panels have been undergoing phase 2 and 3 studies of biomarker validation in the last 5-7 years, such as the GALAD test by Fujifilm-Wako and the methylated DNA marker (MDM) panel by EXACT Sciences, which raises the possibility of a “liquid biopsy” for early detection of HCC. Unfortunately, none of these panels have ever been tested in AI/AN patients. It is likely that the performance of these biomarkers will be significantly different in AI/AN patients than what was described in predominantly Caucasian populations in whom they were developed. The overarching aim of Project 1 is to use a translational approach to develop novel biomarker strategies for early detection of HCC that are designed specifically for AI/AN through 3 interconnected specific aims: SA1: Determine if hepatocellular carcinoma (HCC) in AI/AN patients is associated with unique or enriched genomic and/or epigenomic alterations or patterns of alterations compared to other racial/ethnic groups in order to identify molecular markers, including circulating free methylated DNA (cf mDNA) markers that can be used for surveillance in AI/AN patients at risk of HCC. SA2: (Phase 2 study of biomarker development). Perform a case-control study of 100 cases with T1 or T2 HCC (n=50 AI/AN, n=50 other racial/ethnic groups) and 100 at-risk control patients without HCC with cirrhosis or HBV (n=50 AI/AN, n=50 other racial/ethnic groups) matched by liver disease etiology and cirrhosis severity, to determine and compare the performance characteristics (sensitivity, specificity, AUROC) of the following novel HCC screening biomarker panels: • Circulating methylated DNA marker (MDM) panel (EXACT sciences) • Serum protein-based biomarker panel GALAD (FujiFilm-Wako Diagnostics) If necessary, we will modify GALAD to optimize its performance for AI/AN persons and consider if its performance can be further improved by combining it with cf mDNA markers. SA3: (Phase 3 study of biomarker development). Develop and validate HCC early detection algorithms in an Alaska cohort of AI/AN patients with HCV-cirrhosis or HBV using longitudinal (serial) AFP or GALAD, or modified GALAD developed in SA2 specifically for AI/AN patients, modeled by a Parametric Empirical Bayesian (PEB) and Multivariate Fully Bayesian (mFB) approach.